CASO 213: IAM-EST de cara anterior

Hace unos días repasando el EXAMEN MIR de este año 2016:

Pregunta nº 8 vinculada a la imagen:

DA

Un hombre de 51 años de edad acude al servicio de urgencias por presentar dolor torácico irradiado a miembro superior izquierdo y espalda, de 90 minutos de duración, asociado a malestar general, sudoración y signos de deficiente perfusión periférica. A la auscultación presenta ritmo de galope, tercer ruido; y crepitantes en ambas bases pulmonares. Se realiza coronariografía urgente (ver imagen). Tras evaluar esta imagen. Qué alteraciones electrocardiográficas esperaría encontrar en dicho paciente?:

  1. Elevación de segmento ST en derivaciones II, III y aVF.
  2. Elevación de segmento ST en derivaciones V2, V3, V4  y V5.
  3. Descenso de segmento ST en derivaciones V2, V3, V4  y V5.
  4. Descenso de segmento ST en derivaciones II, III y aVF, asociado a descenso en avL.

La IMAGEN muestra la CORONARIA IZQUIERDA, sus dos ramas: la DIAGONAL y la DESCENDENTE ANTERIOR que se ve amputada / obstruida.

CASO (atendido por Ion): Varón de 55 años, sin factores de riesgo cardiovascular conocidos, con dolor centrotorácico irradiado a espalda y brazo izquierdo de 20 minutos de evolución, acompañado al inicio de cortejo vegetativo.

Exploración general: PA 168/102 Fc 85 SatO2 99. Afectado por el dolor. Bien perfundido, Eupneico. No IY. AC: rítmica sin soplos. AP: normal. Resto anodino.

Pruebas complementarias: Rx Tórax y Analítica (incluidas CPK y Troponina) normales. ECG: RS a 81 x´, elevación de ST en V1-V5 con llamativas ondas T:

CASO 213 IAM ECG 1

Juicio Diagnóstico: SCACEST en cara anterior, de 20 minutos de evolución, Killip I.

– Ion se pone en contacto con hemodinámica para valorar ANGIOPLASTIA PRIMARIA (ACTP). Solicita al 112 una ambulancia medicalizada.

Tratamiento en urgencias: AAS 250 mg. TICAGRELOR 180 mg. NITROGLICERINA: 2 pufs sublingual seguidos de perfusión IV. MORFINA 2 mg IV.

– Avisan de coordinación que las 2 ambulancias medicalizadas (Donosti y Tolosa) están ocupadas, estiman que pueden estar disponibles en +/- 40 minutos. Horror! Para alegrar la fiesta el ECG del paciente cambia: Taquicardia rítmica de QRS estrecho, precedida de múltiples extrasístoles; bien tolerada hemodinamicamente:

CASO 213. IAM ECG 2

– se administra AMIODARONA 300 mg IV y cede la taquicardia.

Comentario: el Hospital Bidasoa es un H. Comarcal, no dispone de Intervencionismo Coronario Percutaneo (ICP). Dista 20 Km del Hospital Donostia: H. terciario de referencia. Nadie pone en duda que la ACTP 1ª es la mejor opción ante un IAM. Si el tiempo estimado puerta-balón supera los 60-90 minutos se indica TROMBOLISIS endovenosa.

Ion ha optado por ACTP 1ª (ha administrado Ticagrelor en lugar de Clopidogrel) pero los tiempos se le vienen encima… Si espera a la medicalizada el tiempo puerta-balón superará los 90 minutos… Decide acompañar él mismo al paciente hasta el H Donostia en una ambulancia sanitarizada (con monitor-ECG y desfibrilador). Al cabo de 60 minutos desde la llegada del paciente a urgencias del Bidasoa se realiza coronariografía (que es similar a la imagen que se muestra al inicio, si bien la lesión no es tan proximal): lesión 100% a nivel del segmento medial de la descendente anterior (B2) -> se realiza ANGIOPLASTIA y colocación de STENT farmacoactivo con buen resultado. FEVI 59% a pesar de alteraciones de la contractilidad segmentaria: aquinesia apical e hipoquinesia moderada anterolateral.

* Desde hace mucho tiempo venimos pidiendo una ambulancia medicalizada con base en Irún. Actualmente dependemos de la de Tolosa que tarda en llegar unos 30/60 minutos según disponibilidad… Por otro lado no es excepcional recibir pacientes críticos que vienen de la zona de Navarra en ambulancia, acompañados por un médico y una enfermera… No me queda claro quién les cubre en su ausencia motivada por el traslado.

PUNTOS CLAVE:

– El tto de elección del IAM-EST es la ANGIOPLASTIA, lo antes posible.

– Si el tiempo estimado PUERTA-BALÓN es mayor de 60/90 minutos se indica FIBRINOLISIS. (intentar ajustarse a tiempo puerta-aguja < 30 minutos).

– Si tras la Fibrinolisis persiste dolor o elevación de ST se indica Angioplastia de RESCATE.

– No olvidar, administrar cuanto antes AAS: 250-300 mg vía oral.

– Añadir CLOPIDOGREL 300 mg en casos de Fibrinolisis

– Si se opta por angioplastia: añadir a AAS, PRASUGREL o TICAGRELOR en lugar de Clopidogrel.

– Individualizar cada caso. Respetar las contraindicaciones.

– Evitar el traslado de un paciente con IAM sin monitorización / desfibrilador.

* Mi felicitación a Ion (compañero de urgencias) por su decisión.

 


Severe bupropion overdose and ECMO: two great saves

ChaNaWiT/shutterstock.com

ChaNaWiT/shutterstock.com

3.5 out of 5 stars

Two Cases of Refractory Cardiogenic Shock Secondary to Bupropion Successfully Treated with Veno-Arterial Extracorporeal Membrance Oxygenation. Heise CW et al. J Med Toxicol 2016 Feb 8 [Epub Ahead of Print]

Abstract

This awesome, exciting paper from Banner University Medical Center in Phoenix describes two teenagers with severe bupropion overdose who survived refractory cardiac arrest after veno-arterial extracorporeal membrane oxygenation (VA-ECMO):

Case 1: A 15-year-old girl was brought to hospital after ingesting up to 90 150-mg bupropion tablets. She had a seizure en route and arrived with pulseless electrical activity (PEA). Return of spontaneous circulation was achieved after 20 minutes of cardiopulmonary resuscitation. She was sent by air-ambulance to a tertiary hospital with a Medical Toxicology service. During transport, she had recurrent episodes of PEA.

At the receiving hospital, the patient had progressive hypoxia and decreased cardiac output with an ejection fraction < 25% on echocardiogram. Because of her worsening condition, VA-ECMO was instituted.

After 4 days, her myocardial function improved but she developed pulmonary hemorrhage and was changed to veno-venous ECMO. She had full recovery after a total of 10 days on veno-arterial and veno-venous ECMO. A follow-up echocardiogram showed an ejection fraction of 60-65%.

A serum bupropion level drawn before ECMO was started was 1883 ng/ml (therapeutic, 50-100 ng/ml.)

Case 2: A 16-year-old girl was brought to hospital after ingesting 60 150-mg bupropion tablets. She had a seizure en route. After initial evaluation she was transported to a tertiary hospital with a Medical Toxicology service.

She arrived at the second hospital in status epilepticus that resolved after treatment with benzodiazepines, propofol and phenobarbital. However, over the next few hours she developed progressive myocardial dysfunction with an ejection fraction of 10% despite aggressive pressor administration. VA-ECMO was initiated.

With improvement in cardiovascular function, ECMO was discontinued on day 3. An echocardiogram revealed an ejection fraction of 60%. An adverse effect of ECMO was lower extremity ischemia resulting in rhabdomyolysis and compartment syndrome requiring fasciotomy. The patient recovered fully except for residual weakness in her right lower extremity.

Bupropion is an especially frightening overdose. It blocks reuptake of dopamine and norepinephrine and can cause rapid deterioration with delayed sudden-onset seizures, metabolic acidosis and myocardial dysfunction. To my mind, these patients certainly would have died were it not for institution of ECMO. Congratulations to the authors and the clinical teams.

To read my Emergency Medicine News column on the use of ECMO in toxicology patients, click here.

 

 

 

ECG of the Week – 15th February 2016

The following ECG is from an 86 yr old female who presented following an episode of chest pain. She has a dual chamber PPM in situ following a prior episode of complete heart block. Old ECG's revealed an A-paced rhythm with no lateral / high lateral T wave inversion.




Click to enlarge

Things to think about

  • What are the key ECG features ?
  • What are the differentials for these features ?

Great education + awesome prizes…all for FREE? Oh yes. Sign up now!

You’ve seen the great lineup (if not take a look below). You know that our educational event on February 18 is going to knock your socks off. What can make this even better? How about games and prizes? Take for instance, our new game, “ED or no ED.”  Watch the clip below and tell us whether or not you think this person will be going to the ED.  

ED or no ED?

What do you think? ED or no ED? Get on Twitter and place your vote @EssentialsofEM #eem16. Let’s find out what the world thinks and watch the thrilling conclusion next Thursday with Rob Orman.

Then, throughout the show, be on the lookout for awesome prize giveaways, ranging from free Essentials conference registration, to free RAPs, to free LLSA. There’s also a rumor that there will be an exclusive conference discount code for a limited time.

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Funtabulously Frivolous Friday Five 135

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia…introducing Funtabulously Frivolous Friday Five 135

Question 1

What was the cause for the most fatalities at Pearl Harbour?pearl harbour

  • NOT Thiopental (but the initial trauma or delayed hemorrhagic shock)
  • It has been a popular myth that Thiopental caused more deaths than the initial trauma but of the 344 patients admitted to the Tripler Army Hospital only 13 died. Thiopental was unlikely to have been responsible for all the deaths and we also know that large induction doses were used before the knowledge that very low doses are required in the shocked trauma patient. [Reference]

Question 2

What is Kehr’s Sign?

  • Acute shoulder tip pain from intra-abdominal fluid or irritants.
  • It is classically supposed to indicate splenic rupture in the supine patient whose legs are raised and they feel left shoulder tip pain. However any cause of diaphragmatic irritation can cause this finding.
  • It has also been questioned whether Kehr (A German hepatobiliary surgeon) really documented this sign in its classic description. [Reference]

Question 3

What metal did Buddy Ebsen (the original Tin Man) react to?tin man

  • Aluminium
  • He developed an allergic reaction and became short of breath forcing him to reprise the role. [Reference]

Question 4

Any guesses for what the Heidelberg Electric Belt is for?electrobelt

  • Impotence
  • Although not sure getting an electric shock to your genitalia would work there was enough recommendations that a mark II version was made. [Reference]

Question 5

During a traumatic resuscitation a thoracotomy maybe performed. One of the injuries that maybe corrected in experienced hands is a pulmonary vein haemorrhage. Who famously died of this injury?

  • Princess Diana
  • Famously used as a case to underlie the importance of quick transfers to hospital as opposed to roadside resuscitation. [Reference]

…and in other news

//www.youtube.com/watch?v=xxZmId9I6vU

The post Funtabulously Frivolous Friday Five 135 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Appendicitis: Pearls and Pitfalls in Adult and Pediatric Populations

Authors: Cristina M. Zeretzke-Bien, MD, FAAP, FAAEM, FACEP (Pediatric EM Attending Physician, University of Florida in Gainesville) and Carolyn Holland, MD, MEd, FACEP (EM/PEM Attending Physician, University of Florida in Gainesville) // Edited by: Jennifer Robertson, MD, MSEd and Alex Koyfman, MD (EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital, @EMHighAK)

Appy Image

Clinical Cases

Case 1: Bill is a 22-year-old (yo) male who presents to the emergency department (ED) with a six-hour history of periumbilical abdominal pain that gradually migrated to the right lower quadrant (RLQ).  His pain is also associated with vomiting and fever.  The patient’s exam shows normal testicles but focal RLQ tenderness with rebound is present.  Is this appendicitis??  What is next step in the evaluation/treatment??

Case 2:  Kevin is a 5 yo male who presents to the ED with a fever and non-specific, generalized lower abdominal pain. On this day, he had one episode of emesis and associated anorexia. Relevant history includes strenuous exercise the day prior. Is this appendicitis??  What is next step in the evaluation/treatment??

Case 3: Elizabeth is a 65 yo female presents to the ED complaining of a 12-hour history of “sour stomach”, suprapubic pain, and dysuria. The patient says that her symptoms feel similar to previous urinary tract infections (UTIs) so she took some left over antibiotics this morning with minimal relief.  She denies fever.  Physical exam reveals normal vital signs (VS) and a soft abdomen with no guarding and only mild tenderness over the suprapubic area. The patient’s urinalysis (UA) shows 10 white blood cells (WBCs), 5 red blood cells (RBCs), and no nitrates, bacteria or squamous epithelial cells.  Is this appendicitis?? What is next step in the evaluation/treatment??

 Introduction/Background

The lifetime risk of appendicitis is 7-8% for all patients. Close to 70% of all cases of appendicitis occur in patients less than 30 years of age with incidence peaks of 10-14 yo males and 15-19 yo females. (Cole MA, 2011) (Bhangu A, 2015) In pregnant females, appendicitis is the most common abdominal emergency not related to pregnancy and it is most commonly seen in the 2nd trimester. (Cole MA, 2011)  Due to the complex nature of symptoms and typically uncommon presentations, may unfortunately be missed at the time of initial evaluation.  This leads to missed appendicitis being the leading source of malpractice suits against emergency medicine physicians in adult patients with abdominal pain. It is also the 2nd leading source of malpractice suits against emergency physicians for children aged 6 to 17 years of age. (Vissers RJ, 2010) (Cole MA, 2011)

 Making the Diagnosis

There is no individual sign or symptom that can reliably exclude appendicitis in any patient. (Vissers RJ, 2010) The three most valuable historical clues include RLQ pain, migration of pain from the periumbilical region to the RLQ, and pain occurring prior to vomiting.  Symptoms helpful in excluding appendicitis include previous histories of similar pain and the absence of RLQ pain. (Cole MA, 2011)  Of note, the classic presentation of a young adult with mid-epigastric pain that migrates to the RLQ over 12-24 hrs is present in as few as 6% of patients with acute appendicitis. The incidence of correctly diagnosing appendicitis in men is between 78-92% of the time and in women only 58-92% of the time.  (Cole MA, 2011).   In adolescent females, it has often been said that the only test needed is a urine pregnancy test (serum or urine B-human chorionic gonadotropin), as appendicitis is a clinical diagnosis.  WBC count and C reactive protein (CRP) have limited utility in the workup of appendicitis, although CRP has been shown to be helpful in detecting perforation or abscess formation. WBC count and CRP are also both components of some common scoring algorithms. (Rothrock SG G. S., 1992)

There are three commonly used scoring systems to evaluate for appendicitis. These can be helpful to risk stratify patients who have signs and symptoms concerning for appendicitis. These three scores include the Alvarado Score (AS), the Pediatric Appendicitis Score (PAS), and the Appendicitis Inflammatory Response Score (AIRS). The Alvarado score is also known as “MANTRELS”, which stands for migration of pain, anorexia, nausea/vomiting, tenderness in the RLQ, rebound tenderness, elevated temperature, and  leukocytosis with a left  shift.  Although both the Alvarado and the PAS scoring systems provide some useful clinical information, both systems have overall poor diagnostic utility when used as sole methods for determining the need for surgery in cases of children with suspected appendicitis” (Cole MA, 2011).  While the Appendicitis Inflammatory Response Score has demonstrated better performance than the Alvarado Score, all scoring systems are, alone, inadequate for determining the need for surgical intervention. They are however, good for risk stratifying the need for imaging studies.  (Andersson M, 2008)

Scoring Systems for diagnosis of appendicitis

AS (Ohle R, 2011) Migration of Pain  – 1Anorexia – 1

Nausea – 1

Tenderness in RLQ – 2

Rebound pain – 1

Elevated temperature – 1

Leukocytosis – 2

Left shift – 1

 

*Score 1-4 (low risk), 5-6 (mod risk), 7-10 (high risk)

AIS (Scott AJ, 2015) Vomiting – 1R iliac fossa pain – 1

Rebound tenderness or guarding

Light– 1

Moderate – 2

Strong – 3

Temp >38.5C 1

WBC

10-14.9 – 1

>=15 – 2

Proportion of PMNs

70-84% – 1

>=85% – 2

CRP

10-49 – 1

>=50 – 2

Score 0-4 (low risk), 5-8 (intermediate risk), 9-12 (high risk)

PAS (Bhatt M, 2009) Migration of pain – 1Anorexia – 1

Nausea/vomiting – 1

Fever  >38C – 1

Cough/percussion/hopping tenderness – 2

WBC >10K – 1

Neutrophilia >7500 cells/mm3 – 1

*Score 0-4 (low risk), 5-7 (moderate risk), >= 8 (high risk)

Patients with AS scores less than 3 are at very low risk for appendicitis or significant alternative pathologies and are thus, not likely to benefit from a computed tomography (CT) scan. (Jones RP, 2015). Patients with moderate risk of appendicitis based on scoring algorithms may benefit from imaging studies.  In general, plain films are not useful in detecting appendicitis, although a visible calcified appendicolith may be present in approximately 10% of patients with uncomplicated appendicitis. (Rothrock SG G. S., 1992)  While plain abdominal x-rays can quickly rule out other causes of abdominal pain such as obstruction or perforation, providers need to remember that perforated appendicitis can be a primary cause of an obstruction (Cole MA, 2011).

Ultrasound (US) is the first choice for imaging in children as children are typically thinner and have less abdominal fat. In addition, US provides the benefit of minimal radiation as compared to the CT scan (Bhangu A, 2015).  US has been found to be nearly 90% sensitive and more than 95% specific for diagnosing appendicitis in children.  Positive findings include an appendiceal diameter greater 6mm or a “target” sign with five concentric layers.  Perforated appendicitis cases make US less accurate.  CT is a more accurate test for diagnosing appendicitis as it has greater sensitivity than US. However, CT raises other issues such as radiation exposure and increased cost. (Garcia Pena BM, 1999) While magnetic resonance imaging (MRI) gets rid of risk of radiation exposure, it has no better accuracy than US in looking for perforated appendicitis.  In adolescent and adult patients, CT has a sensitivity of 92+% in detecting appendicitis. (Bhangu A, 2015)

Practice Guidelines for evaluation of RLQ pain and treatment of appendicitis in ED Patients [adapted from Emergency Medicine Practice (Cole MA, 2011)]

American College of Radiology Appropriateness Criteria – RLQ Pain – Suspected Appendicitis (Smith MP, 2013) In suspected appendicitis, CT with intravenous (IV) contrast [oral (PO) or per-rectum (PR) may not be needed based on institutional preference] is the examination of choice in all patients EXCEPT:·         Pregnant women – US first followed by MRI if needed

·         Children – US first, followed by CT with IV contrast (PO/PR may not be needed based on institutional preference)  if needed

·         If CT is necessary in children, consider a limited RLQ CT

American College of Emergency Physicians Clinical Policy (Howell JM, 2010) In patients with suspicion for appendicitis·         History and physical exam (H&P) to risk stratify

·         Abdominal CT without IV/PO contrast is acceptable, although IV/PO contrast may increase sensitivity

·         In pediatric patients, US should be used to diagnose but not exclude appendicitis

Surgical Infection Society and the Infections Diseases Society of America – (Solomkin JS, 2010) ·         CT is the diagnostic test of choice to identify intra-abdominal infection (such as appendicitis) for adults not undergoing immediate laparotomy

 In children, the age of presentation also causes some issues in early diagnosis and treatment.  Infants and small children under the age of 2 have anatomical differences such as less lymphoid tissue and a funnel-shaped appendix which is more difficult to obstruct.  Because of the difficulty in diagnosis due to atypical presentations, it is often initially diagnosed at autopsy.  In fact, mortality from acute appendicitis exceeds 80% in this population.  Irritability, fussiness, lethargy, and hypotension are often warning signs to consider in the neonate.  (Rothrock SG P. J., 2000) (Lin Y, 2003) (Bundy DG, 2007) Toddlers and preschool age children may have symptoms such as vomiting, abdominal pain, fever, and diarrhea with the presentation, but the focal pain in the RLQ does not usually present until later in childhood.

School age children finally start to present with more reliable exams, but again symptoms very.  Pain with jumping or coughing in this age group is present in 93% and is included in the PAS (Samuel, 2002). School age children also tend to present with fever after 24 hours, focal RLQ pain, and vomiting. Family history may also become relevant in this age group as first degree relatives who have had appendicitis increases the risk 3-10 fold. (Gauderer MWL, 2001)

Adolescents present with a more reliable H&P and often have clinical features that are similar to those seen in adults. They also have behaviors that put them at risk for other pathologies that may mimic appendicitis.  Unprotected sexual activity can place adolescent patients at risk for infections such as epididymitis in males, and pelvic inflammatory disease/tubo-ovarian abscess in females. In females of reproductive age, initial testing should include a pregnancy test, a pelvic exam, and possibly ultrasound imaging. On pelvic exam, cervical motion tenderness can be found in up to 28% of female patients with appendicitis. (Bhangu A, 2015) (Cole MA, 2011) . A pregnancy test is also recommended to evaluate for possible ectopic pregnancy. Ultrasound imaging, preferably transvaginal, is suggested to evaluate for ovarian or fallopian tube pathology. Male patients must undergo a full genitourinary exam to fully evaluate for hernias or testicular pathology.

 Diagnostic Pitfalls

Common findings in cases where the diagnosis of appendicitis was missed include lack of distress, no rebound or guarding, discharge diagnosis of gastroenteritis, and/or lack of timely follow up (Vissers RJ, 2010).

Inflammation and obstruction of the appendix may be limited to the distal portion of the appendix and this is called “tip appendicitis”. Tip appendicitis is often missed on CT scans, causing false negative CT reads (Cole MA, 2011).  Thus, if your index of suspicion is high, even in the setting of a negative CT read, surgical consultation and admission for observation is warranted.

Do not forget about other portions of the physical exam to evaluate alternative causes of RLQ pain. This includes lung auscultation of the lower lung fields to evaluate for pneumonia, a testicle exam in males to evaluate for torsion or epididymitis, and a pelvic exam in females to look for PID or ovarian/fallopian tube pathology (Cole MA, 2011).

Evidence of inflammation in a patient’s urine may be misleading and should not be relied upon to exclude appendicitis (Cole MA, 2011).

Geriatric patients with appendicitis are rare. However, be mindful that older patients may exhibit subtle clinical findings (Vissers RJ, 2010).

 Diagnostic pearls

Heme positive diarrhea is more likely due to an entero-invasive infection (ie – salmonella, shigella, etc) than appendicitis (Cole MA, 2011).

A UA with >30 RBC or >20 WBC is more consistent with a UTI than ureteral inflammation from an inflamed appendix (Cole MA, 2011).

 Management

Major aspects of treating appendicitis in the ED include pain control, IV fluids, antibiotics, and definitive treatment with surgical consultation (Cole MA, 2011) .

Supportive Care

Providing appropriate pain medication does not interfere with the diagnostic accuracy of appendicitis (Green R, 2005).  Volume replacement, as well as keeping the patient NPO (nil per os), are important elements to implement early in the course of treatment for all patients, regardless of age.   If fever exists, it is important to provide antipyretics with acetaminophen IV or PR.

 Antibiotics

Antibiotics with aerobic and anaerobic actions to cover normal gut flora should be used (Bhangu A, 2015).  A 2000 study by Rodriquiz et al demonstrated that antibiotic therapy in pediatric patients with ticarcillin/clavulanate plus gentamicin was associated with fewer infections and faster recovery than the traditional therapy of ampicillin with clindamycin and gentamicin. (Rodriquiz JC, 2000)

 

Surgical Infection Society and the Infections Diseases Society of America – (Solomkin JS, 2010) ·         Antibiotics should be initiated once a patient receives the diagnosis of an intra-abdominal infection or once an infection is considered likely. Patients with septic shock should be given immediate antibiotic therapy. For patients without shock, antibiotics should be given as per protocol in the ED.·         Recommended antibiotics in pediatric patients include a carbapenem (imipenem, meropenem, or ertapenem), a β-lactam/β-lactamase-inhibitor combination (piperacillin-tazobactam or ticarcillin-clavulanate), or an advanced-generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metronidazole.

·         Recommended antibiotics in adult patients: for mild-to-moderate community-acquired infection, ticarcillin-clavulanate, cefoxitin, ertapenem, moxifloxacin, or tigecycline as single-agent therapy or combinations of metronidazole with cefazolin, cefuroxime, ceftriaxone, cefotaxime, levofloxacin, or ciprofloxacin are preferable to regimens with substantial anti-Pseudomonal activity

Definitive therapy

In uncomplicated appendicitis, antibiotic therapy is effective whether given pre or post-operatively.  Based on this, it is not unreasonable to make decisions regarding antibiotic therapy with the admitting surgeon.  Definitive therapy is an appendectomy. Surgeons may utilize the CRP level to triage appendicitis cases to the operating room.  CRP greater than 99 mg/L is present in 90% of cases of complicated appendicitis. Patients with normal CRP levels can have surgery safely postponed up to 12 hours (Sammalkorpi HE, 2015).

 Misdiagnosis (most common) OR Missed Diagnosis

Viral syndrome

Intussusception

UTI

Gastroenteritis

Kidney stones

PID

Ovarian/Testicular Torsion

URI / Pneumonia

Final Clinical Pearls

  • Clinical presentation depends on age of presentation
  • Limit radiation when possible and explore imaging techniques such as ultrasound
  • Labs are sometimes necessary
  • TREAT PAIN! Pain control will not mask the diagnosis.
  • Antibiotics in uncomplicated appendicitis can be a shared decision with surgery.

References/Further reading

Andersson M, A. R. (2008). The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado Score. World Journal of Surgery, 32(8), 1843-49.

Bhangu A, S. K. (2015). Acute appendicitis: modern understanding of pathogenesis. The Lancet, 386, 1278-87.

Bhatt M, J. L. (2009). Prospective validation of the pediatric appendicitis score in a Canadian pediatric emergency department. Academic Emergency medicine, 16(7), 591-6.

Bundy DG, B. J. (2007, July 25). Does this child have appendicitis? Journal of the American Medical Association, 298(4), 438-51.

Cole MA, M. N. (2011). Evidence-based management of suspected appendicitis in the emergency department. Emergency Medicine Practice, 13(10), 1-32. Retrieved from ebmedicine.net

Garcia Pena BM, M. D. (1999). Ultrasonography and liminted computed topography in the diagnosis and management of appendicitis in children. Journal of the American Medical Association, 282, 1041-46.

Gauderer MWL, C. M. (2001). Acute appendicitis in children: the importance of family history. Journal of Pediatric Surgery, 36, 1214-17.

Green R, B. B. (2005). Early analgesia for children with acute abdominal pain. Pediatrics, 116, 978-83.

Howell JM, E. O. (2010). Clinical Policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Annals of Emergency medicine, 55(1), 71-116.

Jones RP, J. R. (2015). The Alvarado score as a method for reducing the number of CT studies when appendiceal ultrasound fails to visualize the appendix in adults. Gastrointestinal Imaging, 204, 519-26.

Lin Y, L. C. (2003). Appendicitis in infancy. Pediatric Surgery International, 19, 1-3.

Ohle R, O. F. (2011). The Alvarado score for predicting acute appendicitis: a systematic review. BMC Medicine, 9, 139. Retrieved from http://www.biomedcentral.com

Paulson EK, K. M. (2003, January 16). Suspected Appendicitis. New England Journal of Medicine, 348(3), 236-42.

Rodriquiz JC, B. D. (2000). Comparison of two antibiotics regiments in the treatment of perforated appendicitis in pediatric patients. International Journal Clinical Pharmacology and Therapeutics, 38, 492-99.

Rothrock SG, G. S. (1992). Plain abdominal radiography in the detection of major disease in children. Annal of Emergency Medicine, 21, 1423-29.

Rothrock SG, P. J. (2000). Acute appendicitis in children emergency department diagnosis and management. Annals of Emergency Medicine, 36, 39-51.

Rothrock, S. (2008). Appendicitis. In R. S. Baren JM, Pediatric Emergency Medicine (pp. 576-81). Philadephia, PA: Saunders Elsevier.

Sammalkorpi HE, L. A. (2015). High admission C-reactive protein level and longer in-hospital delay to surgery are associated with increased risk of complicated appendicitis. Langerbecks Archives of Surgery, 400, 221-28.

Samuel. (2002). Pediatric appendicitis score. Journal of Pediatric Surgery, 37, 877-81.

Scott AJ, M. S. (2015). Risk stratification by the Appendicitis Inflammatory Response score to guide decision-making in patients with suspected appendicitis. British Journal of Surgery, 102(5), 563-72.

Smith MP, K. D. (2013). Right lower quadrant pain — suspected appendicitis. ACR Appropriateness Criteria. American College of Radiology. Retrieved 2015, from American College of Radiology: https://acsearch.acr.org/list

Solomkin JS, M. J. (2010). Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clinical Infectious Diseases, 52(2), 133-64.

Vissers RJ, L. W. (2010). Pitfalls in appendicitis. Emergency Medicine Clinics of North America, 28, 103-18.

Wesson, D. E. (2015, September 14). Acute appendicitis in children: Management. Retrieved from UpToDate: http://www.uptodate.com/contents/acute-appendicitis-in-children-management

 

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